Background: Diabetes is a major cause of morbidity and mortality and a driver of escalating health care costs in the U.S. In attempts to reduce costs, U.S. employers are increasingly offering consumer-directed health plans (CDHPs) that include Health Savings Accounts (HSA) or Health Reimbursement Arrangements (HRA) and high annual deductibles. Recent research has found that CDHPs are associated with concerning impacts on diabetes patients, but growth in CDHP enrollment and their out-of-pocket (OOP) cost trends in this vulnerable population are unknown.

Methods: We used a time series design to assess 2005-2014 annual trends among ∼70 million unique members of all ages insured by a large national commercial insurer from 2005-2014. We analyzed mutually exclusive populations of interest, identified by ACG, comprising: (1) diabetes mellitus with no cardiovascular disease (DM), (2) diabetes with co-morbid cardiovascular disease (DM+CVD), and (3) “healthy” (i.e., ACG score <=1). We used linear models, t-tests and chi-square tests to assess (a) CDHP and non-CDHP prevalence and (b) total annual OOP costs in 2014 dollars.

Results: CDHP prevalence among DM members increased by 2.5% per year (p<0.001), from 1.3% in 20to 23.2% in 2014. DM+CVD members had a similar increase. In 2014, 19.5% of DM+CVD members and 28.7% of healthier members were in CDHPs (p<0.001 for both compared to DM). Annual OOP costs for non-CDHP members were significantly lower than for CDHP members throughout the study period. For example, in 2014, CDHP DM members had average OOP costs of $2103.62 compared to $1379.87 for non-CDHP DM members (p<0.001).

Conclusions: CDHP enrollment has increased markedly over the last 10 years among members with and without diabetes. However, diabetes members were less likely than healthier members to be in CDHPs, particularly if they had co-morbid CVD. Among diabetes patients, OOP costs were significantly higher for CDHP than non-CDHP members.


L.F. Garabedian: Other Relationship; Self; Harvard Pilgrim Health Care. D. Ross-Degnan: None. F. Zhang: None. M.X. Callahan: None. R. LeCates: None. J. Wallace: None. S.B. Soumerai: None. J.F. Wharam: None.

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